Sorry, had a class to go to real quick.
fast,good observation on the meconium. Meconium aspiration is usually pretty obvious at birth, so the sudden onset 18 hours postpartum doesn't quite line up with this.
I am always reluctant to intubate neonates when I am not with my specialty crew. Even with my experience, I would probably bag a neonate in lieu of intubation if I was on a standard 911 truck. Even the smallest blades carried by most EMS systems are going to be on the verge of too big for this kid, and the idea of getting an IV, medicating in the appropriate dose, intubating, dealing with possible vagal tone complications, securing the tube, etc. without a few extra sets of skilled hand is daunting to say the least.
There are no signs of abuse or trauma.
The fluids at maintenance and glucose concerns are great catches! These are a few things a lot of EMS providers miss. High marks for catching these things.
When we look at the vitals of this child, which one jumps out as alarming? The SPO2 of 65% is pretty low, and the blue extremities do seem to correlate with this number, but the pulse is relatively stable. Most would suspect an infant with this SPO2 to be bradying down, right?
One question we need to think about when we see this number in an infant less than 24-48 hours old is where is the SPO2 being measured at? The upper right extremity is the "pre ductal" saturation. The other extremities are considered "post ductal" saturation points. What this means is that the upper right extremity is perfused with blood that does not pass the PDA, where blood that feeds post ductal extremities comes from a point after the PDA, which means it is mixed with both red and blue blood.
usal is correct that oxygen causes the PDA to close. The PDA closes for the most part after the first 24-72 hours of life, with full closure taking a week or so longer. This is when the infant is breathing regular 21% concentration room air. If high flow oxygen is applied, this constriction is much faster. High flow o2 will worsen this infant's condition, in the presence of a ductal dependent lesion.
So, if this SPO2 was taken from the lower left extremity, I would place a monitor on the upper right extremity and see what my SPO2 is. In this case, it could be in the mid to upper 70s to mid 80s, depending on how much mixing is going on. When we see this mis match in pre a post ductal saturation, it is a clear indication that we are likely dealing with a "ductal dependent" lesion, which literally means we are depending on the PDA in order to oxygenate all post ductal circulation. If there is no mismatch, then we are dealing with a whole other scenario, which I may post next time.
Another important test to perform if you can is 4 extremity blood pressures. One ductal dependent defect is coarctation of the aorta, which will cause higher pressures in the upper right extremity or both upper extremities depending on where along the arch the coarctation is located. Elevated pre ductal sats with large difference in upper and lower extremity blood pressures would lead us to a high index of suspicion of coarct, which is definitely ductal dependent, and definitely responds poorly to oxygen.
Alright, sorry to leave half way through, but I have to catch dinner real quick. That will give you guys something to think about for a bit and digest. Come up with some questions or suggestions, and let's meet back here in a few hours.
Good work so far...although I was hoping more people would jump in and play.
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